Behavioral Medicine Pharm

What are indications of lithium?

#1 mood stabilizer in suicidal patients bipolar disorder

A 48-year-old male is brought to the emergency department (ED) by his sister after suffering from loss of consciousness, followed by muscle rigidity and rhythmic contractions, and then a return to a normal state. When asked about medication use, the patient states he is currently being treated with a drug for depression but cannot remember the name. He claims that he has never had a seizure or seizure-like activity prior to this event. Approximately three hours after the first episode, the patient suffers a second one while still in the ED. Which of the following medications is the patient most likely taking? (A) Bupropion (B) Duloxetine (C) Fluoxetine (D) Mirtazapine (E) Nortriptyline

(A) Bupropion

A 35-year-old male is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? (A) Donepezil (B) Lorazepam (C) Phenobarbital (D) Phenytoin (E) Valproate

(B)

A 25-year-old male is hospitalized with symptoms of delusion, paranoia, rambling statements coupled with disorganized thought, and flattened affect. The companion who brings him to the hospital claims this is the first time she has ever witnessed any of these symptoms and is not aware of any medication he is currently taking. Which of the following medications is most appropriate for this patient? (A) Clomipramine (B) Risperidone (C) Sertraline (D) Thioridazine (E) Topiramate

(B) Risperidone The patient is showing signs and symptoms of schizophrenia for which antipsychotic agents are the treatment of choice. Risperidone is an atypical antipsychotic (e.g., second-generation) that has less risk of causing extrapyramidal side effects (EPS) compared to typical antipsychotics (e.g., first-generation) such as thioridazine. Because of the risk of EPS, typical or first-generation antipsychotics are not considered first-line treatments. Even though both typical and atypical antipsychotics appear to have similar efficacy, the atypical agents also tend to be better tolerated, which enhances compliance. (Stroup & Marder, 2014)

A 52-year-old male is brought to the emergency department by his daughter because she recently notices that he gets extremely tired, has periodic tremors in his hands, and suffers from increasing memory lapses. Initial laboratory work shows a serum creatinine of 2.2 mg/dL. His medical history is significant for bipolar disorder, for which he has been taking the same drug for the past 32 months. Which of the following is most likely responsible for the patient's symptoms? (A) Carbamazepine (B) Lithium carbonate (C) Olanzapine (D) Risperidone (E) Valproate

(B) The patient's symptoms are consistent with long-term lithium therapy, which can cause a variety of neuropsychiatric side effects (e.g., tremor, ataxia, mental confusion, fatigue, poor concentration). Lithium is also known to produce adverse effects on the kidneys that can lead to nephrogenic diabetes insipidus and increased serum creatinine concentrations. (Janicak, 2014)

A 35-year-old female diagnosed with depression 3 weeks ago has been taking a medication prescribed by her clinician. Recently, she reports complaints of dry mouth, constipation, and visual sensitivity to bright light. Which of the following medications was the patient most likely prescribed? (A) Bupropion (B) Nortriptyline (C) Phenelzine (D) Sertraline (E) Venlafaxine

(B)Tricyclic antidepressants (e.g., nortriptyline) produce anticholinergic side effects not seen with other types of antidepressants such as SSRIs, SNRIs, and MAOIs. Anticholinergic side effects include dry mouth, constipation, photophobia, blurred vision, urinary retention, and tachycardia. (Hirsch & Birnbaum, 2014a)

A 17-year-old female attempts suicide by swallowing several tablets of acetaminophen. Which of the following is considered the most effective antidote to administer to this patient? (A) Diazepam (B) Flumazenil (C) N-acetylcysteine (D) Sodium bicarbonate (E) Sodium nitroprusside

(C)

A 33-year-old female treated with a first-generation antipsychotic for the past 2 weeks is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? (A) delayed allergic reaction (B) Malignant hyperthermia (C) Neuroleptic malignant syndrome (D) Rhabdomyolysis (E) Serotonin syndrome

(C) Neuroleptic malignant syndrome

A 25-year-old female complains of chest pain, shortness of breath, sweating, and trembling. After an extensive negative work-up, the patient is diagnosed with panic disorder. Which of the following would be most appropriate for sustained treatment? (A) Buspirone (B) Clomipramine (C) Clorazepate (D) Paroxetine (E) Ramelteon

(D)

A 68-year-old male is recently diagnosed with depression associated with the loss of his close sister to an automobile accident. He is currently taking oxybutynin for overactive bladder disease and lisinopril for hypertension. He has no known drug allergies. Which of the following medications would be most appropriate to prescribe for this patient? (A) Alprazolam (B) Amitriptyline (C) Buspirone (D) Desipramine (E) Sertraline

(E) Sertraline

The risk of extrapyramidal side effects (pseudoparkinsonism) and tardive dyskinesia is associated with which class of medications? (A) Amphetamines (B) Benzodiazepines (C) Monoamine oxidase inhibitors (MAOIs) (D) Tricyclic antidepressants (TCAs) (E) Typical (first-generation) antipsychotics

(E) Typical antipsychotics (e.g., haloperidol, chlorpromazine, fluphenazine) can produce extrapyramidal symptoms (EPS) via blockade of dopamine (D2 ) receptors in the nigrostriatum. Symptoms can include akinesia, bradykinesia, mask-like facial expression, tremor, cogwheel rigidity, and postural abnormalities. Tardive dyskinesia may also occur. (Jibson, 2014)

Which of the following is a common adverse effect associated with the use of stimulants such as methylphenidate for attention-deficit hyperactivity disorder (ADHD) in adults? (A) Diarrhea (B) Hypoglycemia (C) Hypotension (D) Paresthesias (E) Reduced appetite

(E) reduced appetite

What is the main SE of bupropion?

** increases risk for seizure - common at high doses

Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)? -The absence of anticholinergic effects -A lower incidence of extrapyramidal effects -Photosensitivity and sedation -No incidence of neuroleptic malignant syndrome

-A lower incidence of EPS

What are the SE of carbamazepine?

-Aplastic anemia & agranulocytosis -Tolerance through auto induction of metabolism -Hyponatremia (3%) -Diplopia -Ataxia -GI upset -Sedation -Wt gain

A client who has been taking buspirone (BuSpar) for two months returns to the clinic for a follow-up. The nurse determines that the medication is effective if there is an absent display of? -Feelings of panic, fear, and uneasiness. -Thought broadcasting or delusions. -Paranoid and suicidal thought process. -Alcohol withdrawal symptoms.

-Feelings of panic, fear, and uneasiness.

The risk of experiencing serotonin syndrome when SSRI's are given with monoamine oxidase inhibitors such as phenelzine (Nardil). Serotonin syndrome is best characterized in which of the following? -Hypotension and urinary retention. -Muscle rigidity and high fever. -A productive cough and vomiting. -Tea-colored urine and constipation.

-Muscle rigidity and high fever.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). A nurse assesses the results of which laboratory study to monitor for adverse effect related to this medication? -White blood cell. -Platelet count. -Liver function studies. -Random blood sugar.

-WBC

Important teaching for a client receiving risperidone (Risperdal) would include advising the client to: -double the dose if missed to maintain a therapeutic level. -be sure to take the drug with a meal because it's very irritating to the stomach. -discontinue the drug if the client reports weight gain. -notify the physician if the client notices an increase in bruising.

-notify the physician if the client notices an increase in bruising.

A newly admit client has started taking bupropion (Wellbutrin). The nurse monitors in which of the following side effects that would indicate an overdosage of the medication? -Headache. -Dizziness. -Constipation. -Seizure.

-seizure

A nurse notes that a client with schizophrenia and receiving an antipsychotic medication is having uncontrolled movement of the lips and tongue. The nurse determines that the client is experiencing?- Hypertensive crisis.- Parkinsonism. -Tardive dyskinesia. -Neuroleptic malignant syndrome.

-tardive dyskinesia

A client taking lithium carbonate (Lithobid) started complaining of nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, blurred vision and ringing in the ears. The lithium level is 2 mEq/L. The nurse interprets this value as: -Normal level. -Toxic level. -Below normal level. -Above normal level.

-toxic level

How long does is take SSRIs to see efficacy?

4-6 weeks

A 22-year-old woman with a history of congenital prolonged QT interval presents to the clinic with dysphoria for the past 2 months. She reports she has felt fatigued, been sleeping more than usual, and had decreased appetite. She has not been interested in doing activities she previously viewed as hobbies. Which of the following medications to treat her suspected condition would require an electrocardiogram prior to initiation?Amitriptyline Duloxetine Escitalopram Venlafaxine

Amitriptyline (TCAs can cause QT prolongation)

Which groups act on GABA?

Benzodiazepines

A 35-year-old woman presents to the clinic wanting to quit smoking. She has a 10 pack-year history of cigarette use. She desires to become pregnant in the next year, although she is currently using barrier methods of contraception. She takes no current medications, has no chronic diseases or drug allergies, and has a normal physical exam, including vital signs and weight. Which of the following treatment options is the best initial choice for this patient? Bupropion Clonidine Nicotine replacement via e-cigarette Nortriptyline

Bupropion

What drug increases both norepinephrine and dopamine?

Bupropion

A 24-year-old woman presents to the clinic complaining of palpitations and depressed mood. On physical exam, she is visibly cachectic with a body mass index of 13 kg/m2. A systolic murmur and systolic click are appreciated at the cardiac apex, and her skin is cool and dry with an abundance of fine, dark hair over her entire body. The patient reports eating only one small salad per day because she has an intense fear of becoming fat. The patient is admitted for evaluation and treatment. Which of the following medications should be avoided? Bupropion Buspirone Olanzapine Sertraline

Bupropion (increased incidence of seizures in eating disorders)

A 45-year-old man presents due to feeling depressed for the last several weeks. He reports he feels very depressed and fatigued, has lost interest in his hobbies, never feels like he gets enough sleep, and has not been able to concentrate at work over the last 3 weeks. You note in the patient's history that he has a history of erectile dysfunction and takes sildenafil as needed. Which of the following medications is the most appropriate treatment for this patient? Bupropion Sertraline Trazodone Venlafaxine

Bupropion (avoids sexual dysfunction)

What are mood stabilizers?

Carbamazepine Oxcarbazepine Lamotrigine

what are typical antipsychotics?

Chlorpromazine Haloperidol thioridazine

What would be the difference in an OD on diazepam vs. an OD on Clonazepam?

Clonazepam has a much longer half-life - and the effects would need a long time to wear off

What is an atypical antipsychotic?

Clozapine Aripiprazole Olanzapine Quetiapine

A 35-year-old patient reports an alcohol intake of two cases of beer per week. This alcohol consumption causes him to miss work frequently, and he reports risky sexual encounters while acutely intoxicated. He would like to discuss options to help him reduce his reliance on alcohol. In addition to behavioral and social interventions, which of the following medications is appropriate?Acarbose Chlordiazepoxide Disulfiram Naloxone

Disulfiram

Which SNRI is superior in regards to sexual functioning?

Duloxetine

A 66-year-old man with a history of hyperlipidemia, type 2 diabetes, and diabetic neuropathy presents for mood disturbance for the last 3 weeks. He reports feeling his life is worthless and has lost interest in activities that used to bring him joy. He has no interest in seeing friends or family and has recurrent thoughts of death, although he has no specific suicidal plan. He reports a 5 lb unintentional weight loss but states he has lost his appetite. He mentions he has not been controlling his glucose over the last 6 months and thinks his neuropathy has worsened. Which of the following medications would be best for this patient? Duloxetine Gabapentin Pregabalin Sertraline

Duloxetine Used in depression + neuropathic pain

A 24-year-old male presenting to the clinic 4 days ago was diagnosed with depression and subsequently prescribed 10 mg/day of fluoxetine. He unexpectedly shows up today and states that he is not experiencing any improvement since starting the medication. What is the best treatment option at this time? (A) Discontinue the fluoxetine and start amitriptyline (B) Discontinue the fluoxetine and start sertraline (C) Double the dose of fluoxetine to 20 mg/day and assure the patient that he will experience improvement in the next 48 hours (D) Maintain the current dose of fluoxetine and add phenelzine to the medication regimen (E) Maintain the current dose of fluoxetine and comfort the patient that the medication may still take several weeks to have its full effect

E

Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects?(A) Acting as dopamine receptor agonists (B) Acting as NMDA receptor antagonists (C) Acting as serotonin receptor antagonists (D) Decreasing reuptake of serotonin and norepinephrine (E) Increasing GABAA receptor-mediated chloride conductance

E

A 20-year-old woman presents to the clinic with anhedonia for 1 month. She reports the activities she usually enjoys are not fun anymore. She also reports hypersomnia, fatigue, weight gain, and difficulty concentrating. You decide to start her on a medication that is in the same class as sertraline. Which of the following medications from this class has the longest half-life? Escitalopram Fluoxetine Fluvoxamine Paroxetine

Fluoxetine

A 26-year-old woman presents to the clinic with sore gingiva. Upon inspecting the patient's mouth, she is noted to have multiple dental caries and tooth discoloration. The patient reports no illicit drug use and states she brushes her teeth regularly, but upon further questioning, she reports frequently forcing herself to vomit. These purging episodes occur after she binges a large quantity of food. She states she feels bad about herself and her weight, eats a great deal in one discrete period of time, then feels relief of anxiety and self-loathing when she purges her food. Which of the following clinical therapeutics is considered first-line for this patient?Electroconvulsive therapy Fluoxetine Mirtazapine Ondansetron

Fluoxetine

A 32-year-old man with a medical history of uncontrolled hypertension and chronic kidney disease is brought to the emergency department in police custody after he was found digging for buried treasure in his neighbor's yard in the middle of the night. He reports he has not slept for days, and he heard voices from God telling him there was treasure in his neighbor's yard. You notice during your assessment he abruptly changes topics and his speech is pressured. He has a negative urine drug screen. The patient reports he has had prior episodes of depression but is currently not taking any psychiatric medications. Your preceptor tells you the best regimen for him includes olanzapine and one other medication. Which of the following is the black box warning for the additional recommended medication for this patient?Agranulocytosis Hepatotoxicity Stevens-Johnson syndrome Weight

Hepatotoxicity (Valproate would be indicated. Lithium is CI d/t hx of CKD)

A 27-year-old woman with bipolar I disorder is evaluated in the office upon urgent request. She was recently started on a new medication after having difficulty tolerating lithium. The patient reports a concerning skin rash that developed over the past 36 hours. She is concerned it may be an allergic reaction related to her new medication and indicates she did not slowly titrate the dose as indicated. On her physical exam, poorly defined erythematous macules and plaques with purpuric necrotic centers are noted on the trunk and the left cheek. With what medication is this reaction most commonly associated? Lamotrigine Lurasidone Quetiapine Valproate

Lamotrigine (SJS syndrome is described)

A 21-year-old woman presents to the emergency department saying she feels as if she will die soon. She is sweating profusely, is tachypneic, and has tachycardia. All other vital signs are within normal limits. Radiologic and laboratory studies reveal no cardiopulmonary disease. The patient states that she tends to have feelings of impending doom when she is in crowded areas like she was earlier today. Which of the following clinical interventions would be most appropriate treatment of this patient's acute symptoms? Buspirone 15 mg Lorazepam 1 mg Mirtazapine 15 mg Sertraline 20 mg

Lorazepam Best for acute panic attack

In a patient being treated for depression and recently released from IP care with hypertensive crisis, what was the patient likely treated with?

MAOI

What are MAOIs?

Nardil, Parnate

A 53-year-old man with a history of schizophrenia was recently transitioned to a new antipsychotic drug after becoming refractory to several other antipsychotics. At his follow-up visit, he has gained 10 pounds. Which antipsychotic most commonly causes weight gain?Haloperidol Olanzapine Prochlorperazine Ziprasidone

Olanzapine

Which of the following clinical therapeutics would be most sedating? Citalopram Fluoxetine Paroxetine Sertraline

Paroxetine

A 55-year-old man who takes medications for hypertension, hyperlipidemia, and major depressive disorder presents to the clinic to discuss sexual dysfunction. He also mentions he has been experiencing nausea recently as well as sedation. Which of the following medications is likely responsible for his symptoms?Bupropion Mirtazapine Paroxetine Venlafaxine

Paroxetine GI SE are common with SSRIs

Which SSRI should be avoided in pregnancy?

Paroxetine (Paxil)

A 25-year-old man presents to the clinic due to breast tenderness and milk discharge from bilateral nipples for the past 3 weeks. Two months ago he presented to the clinic with auditory and visual hallucinations, persecutory thoughts, and paranoia and was prescribed a medication that he believes is causing his current symptoms. Which of the following medications is the most likely culprit?Aripiprazole Divalproex Quetiapine Risperidone

Risperidone

What is a major SE of lamotrigene?

SJS/TEN

What is directly contraindicated while a patient is on an MAOI?

SSRI -need two week "wash out" time -4-6 weeks for fluoxetine tyramine containing ingestion (aged cheese, red wine)

What group is #1 for depression and anxiety?

SSRIs

TCAs are highly effective, but what is preferred and why?

SSRIs are still preferred due to the significant SEs

A 32-year-old woman presents to the psychiatry clinic to discuss treatment for a psychiatric condition. She reports she is unable to maintain a job because she has recurring thoughts she has left a door unlocked at her apartment. These thoughts lead to her returning to her apartment multiple times per day to make sure the apartment doors are locked. She prefers to attempt pharmacologic therapy rather than cognitive behavioral therapy. Which of the following is the most appropriate first-line agent?Duloxetine Risperidone Sertraline Venlafaxine

Sertraline SSRI for OCD

A 26-year-old woman presents to the clinic with excessive worrying for the past 7 months. She reports poor sleep, fatigue, difficulty relaxing, and frequent tension-type headaches. You decide to start her on a medication from the same class as paroxetine. Which of the following is an adverse side effect of this class of medications? Dependence Sexual dysfunction Shortening of the QT interval

Sexual dysfunction (SSRI)`

SNRIs have increased chance of serotonin syndrome when used with what?

St. John's Wort

A 30-year-old woman who is obese and has chronic hepatitis C presents to the clinic with episodes of deep depression followed by weeks of expansive mood, flight of ideas, risk-seeking behavior, and insomnia. Which of the following would need to be monitored frequently if the patient is started on the most appropriate therapy?Fasting plasma glucose Liver enzymes Thyroid function Urine beta-human chorionic gonadotropin

Thyroid function (lithium would be the treatment and can lead to hypothryoidism)

What are SNRIs?

Venlafaxine Duloxtine

What is different about sertraline compared to other SSRIs?

also increases dopamine few drug-drug interactions -dopamine makes us more social, Zoloft works better for mood

What are TCAs?

amitryptyline nortriptyline

What does benztropine do?

an anticholinergic med that helps with the extrapyramidal symptoms (Tardive dykinesia (TD)), acute dystonia

What are SE of TCAs?

anticholinergic weight gain prolonged QT interval

When are benzos useful?

anxiety with panic disorder seizure not d/t hypoglycemia

What conditions require increased dosing with SSRIs?

anxiety, OCD

What two drugs help in managing the SEE of dopamine agonists?

benztropine Dantrolene

What are non-benzo's used for anxiety / sleep?

buspirone hydroxyzine

Which SSRI works for hot flashes in menopause?

citalopram

What are the three C's of TCAs?

coma cardiotoxicity convulsions

What are major SE of Clozapine?

decreased seizure threshold agranulocytosis

Lower doses of SSRIs work well for what?

depression

What should not be treated with a benzo?

depression

When are SNRIs #1?

depression with significant fatigue or pain syndromes

Cognitive enhancers used in alzheimers which are also cholinergic include?

donepezil memantine

What are the three main transmitters where almost all neuro-psych meds work?

dopamine GABA serotonin

Which SSRI has QT prolongation - mostly dose related?

ecitalopram

What can Duloxetine by used for?

fibromyalgia Diabetic peripheral neuropathy

What does too little dopamine lead to?

flat affect stunted emotions apathy difficulty talking

What is the drug of choice for PTSD and bulemia?

fluoxetine

What are common SSRIs?

fluoxetine sertraline paxil

What is a SE of risperidone?

hyperprolactinemia

What is the MOA of SSRIs?

increase serotonin by reducing re-uptake

The mood stabilizers are all also anti-epileptic drugs except for which one?

lithium

What is the only mood stabilizer that is renally excreted?

lithium (+ diabetes insipidus SE)

What is the most common use of TCAs currently?

migraine neuropathy OCD

What are benefits of SSRIs?

preferred for children easy dosing low toxicity in OD less SE

What patient population are mood stabilizers contraindicated in?

pregnancy

What does too much dopamine lead to?

psychosis

What are SE of valproic acid?

sedation tremor •hepatitis/pancreatitis, thrombocytopenia --- works better than the other in "rapid-cycling" bipolar disease (1st generation)

TCAs result in increased levels of what?

serotonin and norepinephrine

What do SNRIs increase?

serotonin and norepinephrine levels

MAOI + SSRI =

serotonin syndrome -acute AMS -restlessness -tremor -hyperthermia -may have sz, coma, death

What are side effects of both SSRIs and SNRIs?

sexual dysfunction inability to orgasm

Paxil (SSRI) - what is different compared to other SSRIs?

shortest half life more anticholinergic effects "discontinuation syndrome"

What does Dantrolene do?

skeletal muscle relaxant used with benzodiazepine for neuroleptic malignant syndrome

What are some uses / benefits of bupropion?

smoking cessation ** weight loss minimal sexual SEs

What is a major concern with SSRIs?

suicidal ideation in patients <24 yo

What group mostly causes the EPS?

typical antipsychotics

What are SE of olanzapine?

weight gain, metabolic syndrome T2DM

What are SE of lithium?

•tremor, weight gain/T2DM, metabolic syndrome •Thyroid dysfunction; arrhythmias; hypercalcemia